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���ki����r� �r�ver�t�on bevice,l�eb��e f'rogram -` <br />; � � � � �ebate� i�ppl�i�c�tican Form - ,� _ ` � <br />� ��v �: _ �� . � � � <br />Praperty Qwner tJame: �� . - ''' '� ' �'�''��::__._. - <br />Installation Address: �..`��Z _��J�"1 /j_t"��._1�t�!-'.�. <br />�� � ���. <br />�ity: �`.�f'�� ' _ _ State: �^_ Zip;_,�:� <br />:f <br />Maifing Address (if dl�ferenfl:���f _.1��r"� �� f �'�— <br />�r? .>- <br />j City: _ G-U"� �`;.�' �� State: ��_�:: Z� ' �`��, <br />� �.__� _ P ___ . _� , , <br />, _ —� , : �:... c� <br />� Emall: ��G�11-C��:`.�-�� ' � c�.�'� x Phone: (�t��� % �`l�-...�-��- /� <br />� <br />: �'"�='fs��� or �'(i. � "`"1 , <br />Total Cost to Install Device from contrar,tar lnvofce}; $� e�'_ �� �' <br />Please verify,tfie following: <br />�m the owner oi tne property SviierQ the 6ack�✓ater prevent�or� device w�s instaNed _ , <br />��-1_.workecl�'with the'�confractor to"r�etermine i�i� Ic�G2fiion for the`backwater preventton-de�l�e an�) <br />� f under�stand ti�at the decision regarding the�locafioit"of the deviee.was m�ne_�= <br />� My contractor inslructed nie no�,v to access, inspect, and mairiiain the device. � <br />�understand thatJ am responsible for rliaintaining the backwater preventioh device and kQeping <br />it in good workii�g order; unless'if is installed in the city rignt-of-way. <br />�� sell iny prpperty, I will.makc po,tential buyers aware of�the baCkwafer-prevenlior� doviGc and <br />� f the necd to inspact arid �maint�in it c�n a r•e:gular basis_ � <br />� ��'�-! am enclasing alf of the necessary papen+rorK (use�the yellow Rebate Submittal Checklist). � � <br />�— <br />Select from tha foNowing: <br />C] Tl1e coritractorident�fied downspouts orother drainage Ilihes thatwere connectad to my sewer <br />� Jine (between�r��y� house. and ihe,insLalled d�vir.e) and rempved, or rorouked�them_ �: � <br />�To my knawledge, my prope�ty has no downspouts or other'drainage connected to my sewer line" <br />(between my hc�us� and the irtstalled deVice). <br />[� There are downspouts or other dr3inago Itnes oonnecied to_my sewnr iine (between'-my hou5e <br />and the ins#alled device): l understand iha� leaving these connections creafes a risk of flooding - <br />`and I accepk that rrsk. <br />� ;; y ('`�. ?, <br />.--f.; � i j .: <br />t � -, � <br />� � �.:.�- �, ��`--� � _ ,�,,, � - <br />�, .< <br />r � '" <br />SigrJature ,� ,,- Ti _ j� Date � .. � t � <br />c` x,..- - _�-' -- � <br />� . .� ,- .-� � _ �, . :� , <br />_ w4 <br />� �4\ ��' '�_ <br />. - . . \ �-.✓'� �4 . <br />. _ . '��l . , , '.. _-, <br />.. ._ �,��..��J. ..t <br />